Foot Drop Surgery Recovery Tracking
Monitor and record your progress and symptoms following foot drop surgery.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which side was affected by foot drop?
*
Left
Right
Both
Current symptoms (select all that apply):
Numbness
Weakness
Pain
Swelling
Improved mobility
Other
Rate your current pain level
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
How far can you walk without support?
*
Not at all
A few steps
Across a room
Several blocks
No limitation
Are you attending physical therapy as recommended?
*
Yes, regularly
Sometimes
No
Have you experienced any complications since surgery?
Infection
Blood clot
Wound healing issues
None
Other
Are you taking your prescribed medications as directed?
*
Yes, always
Sometimes
No
Next scheduled follow-up appointment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Additional comments or concerns
Submit Recovery Update
Should be Empty: